The Bad News Bearers

NTSB is not going to tell you anything 12 months from the incident that you won’t already know within a day or two, if you do your work, and if you don’t abdicate your responsibility

and NTSB responded..

A comprehensive accident investigation cannot be conducted hastily. It is an exhaustive process that involves developing and supporting the most plausible factors contributing to the accident. Also as challenging is the need to rule out factors that we know can lead to an accident. Consider the effort needed to eliminate the following variables that the NTSB has previously identified as contributing to major transportation accidents: operator fatigue (due to irregular and unpredictable crew scheduling, obstructive sleep apnea, circadian disruption); medical conditions (including seizures, diabetes, and color blindness); use of prescription and nonprescription medications; illicit drugs; alcohol; inadequate training and testing of operating and signal rules; poor signal conspicuity; train dispatcher errors; and distraction due to text messaging and cell phone calls. It takes time and great effort to analyze these variables to assess if they played a role in an accident. From the NTSB’s perspective, any conclusion about the cause of the Amtrak accident that was formulated just days after the accident would be purely speculative, incomplete, and lacking a thorough analysis of relevant information.

??

Yeah, it was. It was 14 months ago, and NTSB had just released it determinations based on its thorough, exhaustive, comprehensive investigation of the overspeed derailment of Amtrak 188 at Frankford Jct.

Today a Philadelphia Municipal Court Judge dismissed criminal charges against the locomotive engineer, Brandon Bostian, for the deaths and injuries suffered by passengers for "lack of evidence." See Railway Age.

The Railway Age article does contain this interesting bit of information that apparently slipped through the comprehensive, thorough investigation:

The NTSB found no evidence that Bostian was impaired or using a cellphone. But Tuesday’s testimony revealed that he had a second electronic device, a tablet computer, with him the night of the crash. Eric McClendon from the Philadelphia Police Department’s bomb disposal unit said he found a tablet computer inside Bostian’s backpack in the locomotive. But the device later went missing and was never examined by NTSB investigators for possible use while Bostian was operating the train.﻿

Pardon the expression, sanitized for non-railroad used, but WTF?

As I never tire of pointing out, what we do on a railroad is not that complicated. We can do everything we need to do, and know everything we need to know, relying on Newton's physics rather than Einstein's, much less quauntum mechanics, Heisenberg's uncertainty principle, nor do we need to go anywhere near Schrödinger's cat.

Either the tablet computer existed or it did not. If the tablet did not exist, someone has some explaining to do.

If the tablet did exist, then lots of someones, including the NTSB, has lots of explaining to do.

I was as gratified as anyone when NTSB announced that it had determined that Bostianwas not utilizing his cellphone while operating train #188. I think, however, I pointed out at the time that Bostian might have had a second device, "a burner" that he might have used and then tossed after the derailment.

Not for 1 second did I think my suspicious nature might actually be trumped by real events. That's the thing about reality: no matter how low you go, it's never low enough.

More importantly, and much, much worse, it might indicate that for all its claims to authority and thoroughness, NTSB's investigatory process has a hole so big in it, you could toss an IPad through it.

That's one piece of bad news.

Here's another piece of bad news.﻿

In my favorite movie of all-time Alien (even more favorite than The Third Man) Lambert says to Dallas: "Well, how about a little something to lower your spirits?"

Dallas just wants the short version: "How far to earth?"

Well in the spirit of lowering spirits, William Rockefeller, the locomotive engineer who spun Metro-North train 8808 off the tracks at Spuyten Duyvil killing four and injuring...many, decided to sue Metro-North Railroad for $10 million dollars for essentially failing to protect itself, Metro-North Railroad, from himself. Of course the legal papers don't read that way but Rockefeller is suing for damages, injuries, pain and suffering inflicted on him by....William Rockefeller employed by Metro-North Railroad as a locomotive engineer.

Got that? Mr. Rockefeller's attorney argues that Metro-North Railroad knew that the transition from (originally 75 mph) 70 mph to 30 mph at the curve presented a risk of derailment if the locomotive engineer failed to properly control the speed of his/her train, and should have taken action to prevent such failure.

That much is accurate. Metro-North Railroad officials certainly knew that the required deceleration presented a risk of serious injury and/or death if the locomotive engineer failed to comply with the speed restriction.

In the pursuit of the cool ten million, Rockefeller's attorney deposed JD Riley, former general road foreman of engines for Metro-North regarding "fore-knowledge" of the risk presented by the allowable speed on the curve, and asked if he, JD Riley, had ever proposed mitigations to prevent such an overspeed accident.

JD is one of the two or three most talented railroad operating officers with whom I have ever worked. His assessment of the risk that the DV curve presented in 2005 proved that to me yet another time.

JD Riley had proposed installing a "medium" cab signal code in the body of the curve, forcing and enforcing a speed reduction to 30 mph after an incident in which a locomotive engineer operated around the curve at approximately 55 mph, almost spilling the train.

I know this not from JD Riley's deposition, but from the fact that JD and I discussed installing the cab signal code. I thought it was a great idea, and JD said he was going to bring it up with the vice-president of operations.

Later, JD told me that the vp-o had rejected the proposal.

That might be bad news for Metro-North Railroad as it contests the lawsuit brought by Rockefeller, but it's bad news the railroad has brought on itself by not listening to an experienced line officer doing exactly what experienced line officers are supposed to do: evaluate risks to safe train operations and recommend mitigations.

The railroad opted not to listen to its line officer doing what line officers should be doing.

Nothing can eliminate or even reduce the liability of Metro-North Railroad to the public in this incident. The public knows that. Those who were injured, the families of those killed, aren't pursuing Mr. Rockefeller for damages. They are pursuing, and pursuing rightly, the railroad.

The railroad runs the operation; provides the service. The railroad has the authority over its operations; the railroad takes the responsibility... all of it, when it comes to liability and damages sustained by the public.

The case of Rockefeller himself, he of the $10 million lawsuit, and the two disability pensions (one from the federal Railroad Retirement Board, the other from the MTA) is a bit different. He was the railroad's agent. As the agent, his job was to mitigate the risk presented by the required speed reduction at DV curve, and he failed to properly discharge his obligation to the railroad as its agent; and to the riding public as the railroad's agent.

Whether or not the most advanced automatic control system was available, installed, or operable at the time is immaterial as at any given moment, for any given train the advanced automatic systems may fail, may become inoperable, may have to be disengaged, and Rockefeller, as the railroad's agent, has been trained to operate trains safely in all these circumstances.

When, several years ago, the radio beacon guiding planes landing on a particular runway at San Francisco International Airport failed, thousands of planes landed safely under the control of the crew members who had been trained and qualified to land planes manually.

And then one plane didn't land safely, because the crew members failed in their most basic obligations regarding the landing procedures

Was this accident caused by the failure of the radio beacon? Of course not. The accident was caused by the failure of a particular crew on a particular plane.

That crew, like Mr. Rockefeller, wasn't owed anything by their employer, except a fair hearing at which they can explain their failures, and if the explanations are determined to be inadequate or irrelevant, a dismissal from service in all capacities.

Railroads that listen to experienced line officers, like JD Riley, protect themselves, and others, from more than just lawsuits.

David Schanoes

September 13, 2017

Great moments in rock-n-roll history: February 1967, Aretha Franklin releases the single "I Never Loved a Man..." with the B side "Do Right Woman, Do Right Man."